The Delaware Division of Public Health, in collaboration with the Centers for Disease Control and Prevention (CDC) and the Pennsylvania
Department of Health (PA DOH), is investigating two cases of NDM-producing carbapenem-resistant Pseudomonas aeruginosa. The
first US case was attributed to Delaware with a second in Pennsylvania. Previous cases were found in Europe.

Background

Pseudomonas bacteria are found widely in the environment; however healthy people in the community usually do not develop serious
Pseudomonas infections. Serious infections can occur in patients in the hospital and/or those with weakened immune systems. In
healthcare settings, P. aeruginosa causes pneumonia, bloodstream infections, urinary tract infections, and surgical site
infections.

Individuals with prolonged hospital stays, certain medical conditions like extensive burns, cystic fibrosis, immunocompromising
conditions and those with medical devices such as ventilators and catheters are at highest risk for life-threatening pseudomonal
infections. In hospitals, which are where the most serious infections occur, Pseudomonas can be spread on the hands of
healthcare workers or by equipment that gets contaminated and is not properly cleaned. P. aeruginosa frequently forms a biofilm
(bacterial matrix/plaque) on medical equipment, and colonizes tissues of long-stay patients.

Current Situation

The NDM (New Delhi Metallo-beta-lactamase) gene is an antibiotic resistance gene that confers resistance to carbapenems and other
β-lactam antibiotics. Bacteria that have this gene have also been found to be resistant to most other classes of antibiotics and are
very difficult to treat. NDM has been well described among Enterobacteriaceae, such as Klebsiella spp and Escherichia
coli (Carbapenem-resistant Enterobacteriaceae- CRE), isolated in the US and elsewhere in the past several years. According to the
CDC, there have been 103 NDM-producing Enterobacteriaceae reported to CDC since 2009.

The situation is different with Pseudomonas, however, as this case from DE represents the first time the NDM gene is reported in
a Pseudomonas isolate in the United States. To our knowledge, there have been only 4 cases of NDM-producing Pseudomonas
described in the literature. All 4 were isolated in Europe between 2010 and 2013.

The Delaware case is an 81-year-old from New Castle County and represents the first case of NDM in Pseudomonas in Delaware and
in the United States. This individual is currently receiving medical care in Pennsylvania after a hospital stay in Delaware. To our
knowledge, as of today, this is the only case of this infection in a Delaware resident. According to the CDC, a second case has recently
been identified in a Pennsylvania resident. Investigations in Delaware and Pennsylvania are ongoing to further characterize the
situation.

Know if patients with multidrug-resistant organisms like CRE or carbapenem-resistant Pseudomonas are hospitalized at your
facility, and stay aware of infection rates. Ask if a patient has received medical care somewhere else, including another country.

Place patients currently or previously colonized or infected with CRE or carbapenem-resistant Pseudomonas on Contact
Precautions. Whenever possible, dedicate rooms, equipment, and staff to patients with CRE or carbapenem-resistant Pseudomonas.

As part of Contact Precautions, wear a gown and gloves when caring for patients colonized or infected with these bacteria.

Perform hand hygiene – use alcohol-based hand rub or wash hands with soap and water (if hands are visibly soiled) before and
after contact with patients or their environment.

Alert the receiving facility when you transfer a patient with CRE or carbapenem-resistant Pseudomonas, and find out when a
patient with CRE or carbapenem-resistant Pseudomonas transfers into your facility.